QUEST Integration – Hospital Inpatient Confinements

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

Acute Care

Acute inpatient hospital care for medical, surgical, maternity (including newborn) rehabilitation and behavioral health conditions is covered. Services include room and board, nursing care, medical supplies, equipment and drugs, diagnostic services, physical therapy, occupational therapy, audiology, speech-language pathology, and other medically necessary services. Inpatient confinement for Long Term Care (ICF/SNF and ICF/SNF waitlisted), Behavioral Health and services that are normally done on an inpatient basis require precertification.

Inpatients in acute facilities whose conditions improve to the point that they require a lower level of care than acute, i.e. skilled nursing or intermediate care, and who are awaiting the availability of the appropriate level of care bed, are also covered during the acute-waitlisted stay until the patient can be transferred.

Services can also be provided in the acute setting for patients who are waitlisted for transfer to a lower level of care.

Long Term Care

Persons who need 24-hours a day assistance and need care provided by licensed nursing personnel and paramedical personnel on a regular, long-term basis are covered for nursing facility, skilled nursing facility, or intermediate care facility services. Services can be provided in a free-standing facility or in a distinct part of a facility that is licensed and certified as meeting the requirements to provide these services. Services can also be provided in the acute setting for patients who are awaiting transfer to a lower level of care bed or facility, i.e. waitlisted patients.

Care includes independent and group activities, meals and snacks, housekeeping and laundry services, nursing and social work services, nutritional counseling, pharmaceutical services and rehabilitative services.

Waitlisted confinements of patients awaiting transfer to a lower level of care pending the availability of a bed are covered, e.g., a patient in an SNF level of care waiting transfer to an ICF level of care.

Revision History